Pathways to Financial Empowerment - Online Registration

CONTACT
INFORMATION

Hi, we look forward to working with you and helping you achieve your financial goals. Let's get started by answering the questions below. This form should take no more than 10 minutes and will help your counselor prepare for your session and spend less time writing down information during the session. Before you proceed, please read this client service agreement.

First Name

Last Name

Birthdate

Please enter the birthdate in the following format: mm/dd/yyyy.

Mobile Phone

By providing your mobile number above, you acknowledge that we are
able to send SMS messages to this number. If you would NOT like to receive SMS
messages, please check the "SMS Opt-out" box below.

SMS Opt-out?

Email

Communication Preference

Preferred Language

Street Address

City

State

Zip/Postal Code

YOU AND YOUR
FAMILY

Race

Gender

Highest Level of Education Attained

Total Number of People Living in Your Household (including you and your children)

Number of Dependents

Marital Status

How did you hear about us/our services?

How did you hear about us/our services? OTHER

EMPLOYMENT
STATUS

Employer

Are you hourly or salaried?

Monthly Earned Income After Taxes (take-home pay from all sources)

CFSI QUESTIONS

This program leverages the CFSI Financial Health Score® Toolkit.

Over the past year, how would you describe your household's income & expenses?

Over the past year, which of the following statements describes how well your household is keeping up bills?

How long could your household make end meet if you had to live off savings that are readily available to cover basic monthly expenses?

How confident are you that you will have enough money saved for your long-term financial goals?

As of today, how would you describe your household’s current level of debt?

How would you rate your credit score?

How confident are you that your household’s insurance policies will provide you with enough support in case of an emergency?

To what extent do you agree or disagree with the following statement: “My household plans ahead financially.”

Are you interested in
discussing your debt and credit in your session?

If so, please read this,
check off the box below and provide your Social Security Number:

I hereby authorize and
instruct Opportunities Credit Union to obtain and review my credit report.
Additionally, I authorize Opportunities Credit Union to obtain and review my credit
report at additional times within the next 24 months so Opportunities Credit Union,
Inclusiv and NTFP and can evaluate the effectiveness of the counseling services
and the Pathways program. I understand that Opportunities Credit Union will obtain
these credit reports through what are known as “soft pulls” that will not have
any adverse effect on my credit history, rating, or score. I understand that
records of my credit report(s) and scores will be kept on file by the Pathways
program for program evaluation purposes only.

You will be able to read
these again in your session with the counselor.

CR Auth

By checking this box, you give your credit union permission to obtain your credit report from any of the three credit reporting agencies for the duration of your engagement in our services and for up to 24 months thereafter, for program evaluation purposes. Your score will not be affected.